Original Research Obstetrics| Volume 222, ISSUE 2, P179.e1-179.e9, February 2020

Outcomes following a clinical algorithm allowing for delayed hysterectomy in the management of severe placenta accreta spectrum

Published:August 27, 2019DOI:


      The incidence of placenta accreta spectrum is rising. Management is most commonly with cesarean hysterectomy. These deliveries often are complicated by massive hemorrhage, urinary tract injury, and admission to the intensive care unit. Up to 60% of patients require transfusion of ≥4 units of packed red blood cells. There is also a significant risk of death of up to 7%.


      The purpose of this study was to assess the outcomes of patients with antenatal diagnosis of placenta percreta that was managed with delayed hysterectomy as compared with those patients who underwent immediate cesarean hysterectomy.

      Study Design

      We performed a retrospective study of all patients with an antepartum diagnosis of placenta percreta at our large academic institution from January 1, 2012, to May 30, 2018. Patients were treated according to standard clinical practice that included scheduled cesarean delivery at 34–35 weeks gestation and intraoperative multidisciplinary decision-making regarding immediate vs delayed hysterectomy. In cases of delayed hysterectomy, the hysterotomy for cesarean birth used a fetal surgery technique to minimize blood loss, with a plan for hysterectomy 4–6 weeks after delivery. We collected data regarding demographics, maternal comorbidities, time to interval hysterectomy, blood loss, need for transfusion, occurrence of urinary tract injury and other maternal complications, and maternal and fetal mortality rates. Descriptive statistics were performed, and Wilcoxon rank-sum and chi-square tests were used as appropriate.


      We identified 49 patients with an antepartum diagnosis of placenta percreta who were treated at Vanderbilt University Medical Center during the specified period. Of these patients, 34 were confirmed to have severe placenta accreta spectrum, defined as increta or percreta at the time of delivery. Delayed hysterectomy was performed in 14 patients: 9 as scheduled and 5 before the scheduled date. Immediate cesarean hysterectomy was completed in 20 patients: 16 because of intraoperative assessment of resectability and 4 because of preoperative or intraoperative bleeding. The median (interquartile range) estimated blood loss at delayed hysterectomy of 750 mL (650–1450 mL) and the sum total for delivery and delayed hysterectomy of 1300 mL (70 –2150 mL) were significantly lower than the estimated blood loss at immediate hysterectomy of 3000 mL (2375–4250 mL; P<.01 and P=.037, respectively). The median (interquartile range) units of packed red blood cells that were transfused at delayed hysterectomy was 0 (0–2 units), which was significantly lower than units transfused at immediate cesarean hysterectomy (4 units [2–8.25 units]; P<.01). Nine of 20 patients (45%) required transfusion of ≥4 units of red blood cells at immediate cesarean hysterectomy, whereas only 2 of 14 patients (14.2%) required transfusion of ≥4 units of red blood cells at the time of delayed hysterectomy (P=.016). There was 1 maternal death in each group, which were incidences of 7% and 5% in the delayed and immediate hysterectomy patients, respectively.


      Delayed hysterectomy may represent a strategy for minimizing the degree of hemorrhage and need for massive blood transfusion in patients with an antenatal diagnosis of placenta percreta by allowing time for uterine blood flow to decrease and for the placenta to regress from surrounding structures.

      Key words

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      Linked Article

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        American Journal of Obstetrics & GynecologyVol. 223Issue 2
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          We appreciate the comments of Matsuzaki et al1 regarding our work,2 in which we presented our experience with a clinical protocol allowing for delayed hysterectomy for severe placenta accreta spectrum (PAS). In our study, we presented delayed hysterectomy as an alternative to immediate hysterectomy in select cases, as delayed hysterectomy was associated with less blood loss and lower transfusion requirements. We acknowledge that this retrospective study did not allow conclusions regarding the superiority of immediate vs delayed hysterectomy and that the groups likely differed in a priori surgical risks.
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      • Delayed hysterectomy versus continuing conservative management for placenta percreta: which is better?
        American Journal of Obstetrics & GynecologyVol. 223Issue 2
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          We read with great interest the article regarding outcomes of delayed hysterectomy in the management of placenta percreta by Zuckerwise et al.1 They focused on delayed hysterectomy for placenta percreta and concluded that this approach may improve surgical morbidity.1,2 We have 2 questions on this manuscript.
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      • Delayed hysterectomy: a laparotomy too far?
        American Journal of Obstetrics & GynecologyVol. 222Issue 2
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          There is no doubt that the incidence of placenta accreta spectrum (PAS) disorders is rising and that this is linked to rapid increase caesarean delivery rates worldwide.1 The associated risks of maternal morbidity and mortality has encouraged increasing research into the safest methods for managing this complex condition.
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